Request for free drinks on the Holdiplanet:

a) Name, Contact-Data:

Full name (first, name): 

Nickname: 

Mail-Address, Copy to: 

Mobile-phone: 

b) Free drink appointment:

Preferred date/time: 

(dd.mm.yyyy) (hh:mm)

Alternative date/time: 

(dd.mm.yyyy) (hh:mm)

Preferred drink:  

Other preferred drink:  

Another preferred drink:  

Preferred junk food:  

Underwear-size

(required by females only)

Preferred underwear

(required by females only)

Your comments:

(please give a reason for your request and/or more details to your request e.g. alternative dates, drinks, foods, underwear...) 

c) Please enclose a photo
(required by females only, full body, clothes are optional):

Select image:  

* image file: (don't change!)

Submit form as: